The publication of Donna Ockenden's 400-page report into maternity care failures at Nottingham University Hospitals NHS Trust has exposed a shocking catalogue of errors, including the death of baby Harriet Hawkins in 2016 and a subsequent cover-up. The report highlights trust-wide problems with staffing, culture, and leadership, as well as broader NHS flaws, citing the 2022 Messenger review's finding that political pressure can lead bosses to prioritize hierarchy over service-users.
Key Findings and Immediate Impact
The report contains around 100 action points, making implementation a daunting task. Next week, Valerie Amos will add her own investigation into maternity care in England, joining over 700 recommendations from earlier reports. Former health secretary Wes Streeting had pledged to chair a new taskforce, but his resignation alarmed campaigners, who now demand a commitment to maternity care improvement that is non-negotiable and grounded in practicalities. The review points to a damaging split between strategy and operations in Nottingham, which NHS England must avoid replicating.
Safe Staffing and Cultural Issues
Safe staffing emerges as a crucial factor, with nine in 10 midwives reporting understaffed wards. Experts including Prof Alison Leary, deputy president of the Royal College of Nursing, believe minimum nurse-patient ratios should be set out in law. However, workforce shortages were not the only problem. The review identifies a 2006 merger as a cause of later failures, with two separate maternity units operating in silos, insular and sometimes toxic cultures, poor communication between doctors and midwives, and deeply troubling incidents of racism.
Financial Penalties and Police Investigation
Nottingham paid fines totalling almost £2.5 million in 2023 and 2025 following Care Quality Commission investigations into failures in the care of babies including Wynter Andrews. A police inquiry, Operation Perth, is considering corporate manslaughter charges and has made two arrests linked to mortuary services. Ockenden herself is booked to lead two further investigations in Leeds and Sussex.
Families Demand Statutory Public Inquiry
Nottingham campaigners are furious at the lack of cooperation from senior NHS leaders, many of whom refused to give evidence. Some argue that local, expert-led investigations are insufficient and want a statutory public inquiry instead. However, it is not clear that another years-long inquiry with an even wider remit would serve the public interest. The families failed by the NHS deserve anger on their behalf, but there is no guarantee that further examination of past mistakes would lead to improvement.
Urgent Need for Ministerial Response
At a time when maternal deaths have climbed to a 20-year high, and worse outcomes for black, minority-ethnic, and economically deprived mothers are disturbingly apparent, what is needed urgently is a response from ministers to recommendations including a new standard for perinatal care and a plausible plan to raise standards. The devastating neglect revealed in this report must never be repeated.
